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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl icati Is,hh re ade to c ry on b Ines in th jurisdictional area of th a J uin Lo al IthM 4 <br /> HBusiness Name (DBA} ��� � 'Jr sad Address -- <br /> aOwner Address <br /> Firm Partners, Addresses and T I pone Nu bers <br /> CL <br /> Business Telephone No. Emergency Telephone Na. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) G� <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST _ <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test cation Test Date/Time <br /> 4. PSANITATION PERMIT <br /> Job Add s/Locati n <br /> Owner Address <br /> PEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY EW REPAIR ❑ OTHER Ird <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and re lations o e San Joa in Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> �x FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY [I PER UNIT la PER SITE ❑ EACH ❑ January 1 &Received B ry 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ VIV <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> le DATE DATE AREMITTE <br /> AMOUNT <br /> FEE II/J Sr <br /> LESS <br /> PRORATION t <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0757 <br /> Received by Date Receipt No. Permit No. I Issua ce Date Mailed elite d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOC TON,C 95201 - <br />